NCC204766_NOT Signed Certification_20241008

Notice Certification
Directions:
Print this form, complete,scan and upload to the electronic NOT(Rescission)form.
Then,mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N.Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM TIL YOUR T REQUEST HAS BEEN REVIEED AND APPROVED.
TIDE FORM YOU MAIL MUST_BE COL T ITH AN ORIGINAL SIGNATURE T DIGITAL)[40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: `-[
Name of Project: kn 41i- si\ (. ) ' U\o.
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement,representation, or
certification in any application, record, report,plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article. . .shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject facility. I am familiar with the information contained in this request,and to the best of my knowledge
and belief, such information is true, complete,and accurate. �r�
Legally Responsible Organizational Entity(must match eNOT): `A(J \ ) t-
*Legally Responsible Person (must match eNOT): Re"
*Title of Legally Responsible Person: Car\5 ° Uri fi f{' , " ` ,3
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
\tc \ 5 7,\ICI\tWtt,e\*- ?tY)e)u\ \ntiA: \m`f`
*Signature. Date: \ ' j -
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president,secretary, treasurer, or vice president, or a manager that is authorized in
accordance with Part iV,Section B, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.
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